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General NPI Number Information
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NPI Number | 1720612500
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Entity Type | Individual
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Provider Name | MARCTIES PENDERGRASS
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Gender | Male
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Dates
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Enumeration Date | 03/02/2020
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Last Update Date | 03/02/2020
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Provider Practice Location Address
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Address Line | 1800 2ND LOOP RD STE 3
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City | FLORENCE
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State | SC
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Zip | 29501-6180
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Country | US
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Telephone | 843-667-1905
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Fax | 843-667-1723
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Provider Business Mailing Address
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Address Line | 2928 CREEK RD
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City | LAKE CITY
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State | SC
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Zip | 29560-6632
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Country | US
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Telephone | 843-550-7884
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 7350
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License Number State | SC
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